CHLAMYDIA

• The family Chlamydiaceae consists of one genus

Chlamydia with three species that cause human
disease:
• C. trachomatis, which can cause urogenital
infections, trachoma, conjunctivitis, pneumonia
and lymphogranuloma venereum (LGV)
• C. pneumoniae, which can cause bronchitis,
sinusitis, pneumonia and possibly atherosclerosis
• C. psittaci, which can cause pneumonia
(psittacosis).
 Cont,…
• Chlamydia are small obligate intracellular
parasites and were once considered to be
viruses. However, they contain DNA, RNA and
ribosomes and make their own proteins and
nucleic acids and are now considered to be
true bacteria. They possess an inner and outer
membrane similar gram-negative bacteria and
a lipopolysaccharide but do not have a
peptidoglycan layer.
 Physiology and Structure
A. Elementary bodies (EB)
EBs are the small (0.3 - 0.4 μm) infectious
form of the chlamydia.
B. Reticulate bodies (RB)
RBs are the non-infectious intracellular from
of the chlamydia. They are the metabolically
active replicating form of the chlamydia.
 Developmental cycle
• The EBs bind to receptors on susceptible cells and
are internalized by endocytosis and/or by
phagocytosis. Within the host cell endosome the
EBs reorganize and become RBs. The chlamydia
inhibit the fusion of the endosome with the
lysosomes and thus resist intracellular killing. The
entire intracellular life cycle of the chlamydia
occurs within the endosome. RBs replicate by
binary fission and reorganize into EBs. The
resulting inclusions may contain 100 - 500
progeny .Eventually the cells and inclusions lyse
(C. psittaci) or the inclusion is extruded by
reverse endocytosis (C. trachomatis and C.
pneumoniae)
Life cycle of chlamydia
 Chlamydia trachomatis
• C. trachomatis is the causative agent of trachoma,
oculogential disease, infant pneumonia and
lymphogranuloma venereum LGV).

• A. Biovars - C. trachomatis has a limited host range and

only infects human epithelial cells (one strain can infect
mice). The species is divided into three biovars
(biological variants): trachoma, LGV and mouse
pneumonitis.

• B. Serovars - The human biovars have been further

subdivided in to several serovars (serological variants;
equivalent to serotypes) that differ in their major outer
membrane proteins and which are associated with
different diseases
 Pathogenesis and Immunity
• C. trachomatis infects non-ciliated columnar
epithelial cells. The organisms stimulate the
infiltration of polymorphonuclear cells and
lymphocytes which leads to lymphoid follicle
formation and fibrotic changes. The clinical
manifestations result from destruction of the
cells and the host inflammatory response.
Infection does not stimulate long lasting
immunity and reinfection results in a
inflammatory response and subsequent tissue
damage.
 Epidemiology
1. Ocular infections
• C. trachomatis (biovar: trachoma) is found worldwide primarily in areas of
poverty and overcrowding. It is estimated that 500 million people are
infected worldwide and 7 - 9 million people are blind as a consequence. C.
trachomatis biovar: trachoma is endemic in Africa, the Middle East, India
and Southeast Asia. In the United States, Native Americans are most
commonly infected. Infections occur most commonly in children. The
organism can be transmitted by droplets, hands, contaminated clothing,
flies, and by passage through an infected birth canal.

2. Genital tract infections

• a. C. trachomatis (biovar: trachoma) is the most common sexually
transmitted bacterial disease in the United States (4 million new cases each
year) and 50 million new cases occur yearly worldwide. In the United States,
the highest infection rates occur in Native and African Americans with a
peak incidence in the late teens/early twenties.
• b. C. trachomatis (biovar: LGV) is a sexually transmitted disease that occurs
sporadically in the United States but is more prevalent in Africa, Asia and
South America. Humans are the only natural host. Incidence is 300 - 500
cases per year in the United States with male homosexuals being the major
reservoir of the disease.
 Clinical Syndromes
1. Trachoma
Chronic infection or repeated reinfection with C. trachomatis (biovar: trachoma)
results in inflammation and follicle formation involving the entire conjunctiva.
Scarring of the conjunctiva causes turning in of the eyelids and eventual scarring,
ulceration and blood vessel formation in the cornea, resulting in blindness. The name
trachoma comes from 'trakhus' meaning rough which characterizes the appearance of
the conjunctiva. Inflammation in the tissue also interferes with the flow of tears
which is an important antibacterial defense mechanisms. Thus, secondary bacterial
infections occur.

2. Inclusion conjunctivitis - Inclusion conjunctivitis is caused by C. trachomatis

(biovar: trachoma) associated with genital infections (serovars D - K). The infection is
characterized by a mucopurulent discharge, corneal infiltrates and occasional corneal
vascularization. In chronic cases corneal scarring may occur. In neonates infection
results from passage through an infected birth canal and becomes apparent after 5 -
12 days. Ear infection and rhinitis can accompany the ocular disease.

3. Infant pneumonia - Infants infected with C. trachomatis (biovar: trachoma;

serovars: D - K) at birth can develop pneumonia. The children develop symptoms of
wheezing and cough but not fever. The disease is often preceded by neonatal
conjunctivitis.

4. Ocular lymphogranuloma venereum - Infection with the LGV serovars of C.

trachomatis (biovar: LGV) can lead to oculoglandular conjunctivitis. In addition to the
conjunctivitis, patients also have an associated lymphadenopathy.
 Clinical Syndromes Cont,..
6. Urogenital infections
In females the infection is usually (80%) asymptomatic but symptoms can include
cervicitis, urethritis, and salpingitis. Postpartum fever in infected mothers is common.
Premature delivery and an increased rate of ectopic pregnancy due to salpingitis can
occur. In the United States, tubal pregnancy is the leading cause of first-trimester,
pregnancy-related deaths. In males, the infection is usually (75%) symptomatic.

After a 3 week incubation period patients may develop urethral discharge, dysuria and
pyuria. Approximately 35 - 50% of non-gonococcal urethritis is due to C. trachomatis
(biovar: trachoma). Post-gonococcal urethritis also occurs in men infected with both
Neisseria gonorrhoeae and C. trachomatis. The symptoms of chlamydial infection occur
after treatment for gonorrhea because the incubation time is longer.

Up to 40% of women with untreated (undiagnosed) chlamydia will develop pelvic

inflammatory diseases and about 20% of these women will become infertile. Many
untreated cases (18%) result in chronic pelvic pain. Women infected with chlamydia have
a 3 - 5 fold increased risk of acquiring HIV.

7. Reiter's syndrome
Reiter's syndrome is a triad of symptoms that include conjunctivitis, polyarthritis and
genital inflammation. The disease is associated with HLA-B27. Approximately 50 - 65% of
patients have an acute C. trachomatis infection at the onset of arthritis and greater than
80% have serological evidence for C. trachomatis infection. Other infections (shigellosis or
Yersinia enterocolitica) have also been associated with Reiter's syndrome.
 Cont,…
7. Lymphogranuloma venereum (C. trachomatis biovar: LGV)
The primary lesion of LGV is a small painless and inconspicuous
vesicular lesion that appears at the site of infection, often the penis
or vagina. The patient may also experience fever, headache and
myalgia. The second stage of the disease presents as a marked
inflammation of the draining lymph nodes. The enlarged nodes
become painful 'buboes' that can eventually rupture and drain.

• Fever, headache and myalgia can accompany the inflammation of

the lymph nodes. Proctitis is common in females; lymphatic
drainage from the vagina is perianal. Proctitis in males results from
anal intercourse or from lymphatic spread from the urethra. The
course of the disease is variable but it can lead to genital ulcers or
elephantiasis due to obstruction of the lymphatics.
 Laboratory diagnosis
There are several laboratory tests for diagnosis of C. trachomatis but the sensitivity of the tests will
depend on the nature of the disease, the site of specimen collection and the quality of the
specimen. Since chlamydia are intracellular parasites, swabs of the involved sites rather than
exudate must be submitted for analysis. It is estimated that as many as 30% of the specimens
submitted for analysis are inappropriate.

1. Cytology - Examination of stained cell scrapings for the presence of inclusion bodies has been
used for diagnosis but this method is not as sensitive as other methods.

2. Culture – Culture in susceptible cells is the most specific method for diagnosis of C. trachomatis
infections.

3. Antigen detection - Direct immunofluorescence and ELISA kits that detect the group specific LPS
or strain-specific outer membrane proteins are available for diagnosis. Neither is as good as culture,
particularly with samples containing few organisms (e.g. asymptomatic patients).

4. Serology - Serological tests for diagnosis are of limited value in adults, since the tests do not
distinguish between current and past infections. Detection of high titer IgM antibodies is indicative
of a recent infection. Detection of IgM antibodies in neonatal infection is useful.

5. Nucleic acid probes - Three new tests based on nucleic acid probes are available. These tests are
sensitive and specific and may replace culture as the method of choice.
 Treatment and prevention
• Tetracyclines, erythromycin and sulfonamides
are used for treatment but they are of limited
value in endemic areas where reinfection is
common. Vaccines are of little value and are
not used. Treatment coupled with improved
sanitation to prevent reinfection is the best
way to control infection. Safe sexual practices
and prompt treatment of symptomatic
patients and their sexual partners can prevent
genital infections.